As HHS gears up to finalize long-awaited rules on interoperability and information-blocking, much of the industry has focused on their likelihood to spur development of new patient-facing apps. But the rules will also open new opportunities for some long-standing interoperability players: health information exchanges.
HIEs have been key players in facilitating healthcare interoperability to date, with about 70% of hospitals participating in at least one nationwide network, according to a data brief released late last year by the Office of the National Coordinator for Health Information Technology. eHealth Exchange, a nationwide health information network that was incubated as a federal program under the ONC in 2006, is one of those groups.
"I think they're giving HIEs a nice little nudge to mature faster," said Jay Nakashima, executive director of the eHealth Exchange.
The ONC handed off the eHealth Exchange to the Sequoia Project in 2012, where it has continued as a private-sector effort. Last year it spun out into an independent not-for-profit.
About half of hospitals participate in a state, regional or local HIE, in addition to a national one, according to the ONC brief.
"The biggest change that we've seen is the demand for reach," Nakashima said of providers' evolving expectations for HIEs.
With a growing focus on care coordination, providers need to share data with their neighbors and have the option to connect with a wider range of organizations.
"Their patients travel; their patients work," Nakashima said. "Their patients certainly go outside of their various providers' networks."
The ONC's and CMS' proposed rules will likely shake up the interoperability landscape and change how providers and health plans exchange data with patients and each another. That could open new opportunities for HIEs beyond aggregating patient data.
Figuring out a core business case is imperative as some HIEs have struggled to establish a sustainable business model.
Many HIEs were stood up with the help of government funding from the American Recovery and Reinvestment Act of 2009, said Mari Greenberger, senior director of informatics at the Healthcare Information and Management Systems Society. Since then, many smaller HIEs have shuttered. The exchanges will need to find a new funding source to avoid that fate, which might involve relying on subscription fees from members.
That may mean providing a business case beyond traditional data-sharing. HIEs should assess what the "impactful services" are for their specific members and patient population, and then create solutions around those core competencies, according to Greenberger.
The interoperability and information-blocking proposals released early this year would require providers and insurers to set up a new infrastructure for data exchange—standardized application programming interfaces. APIs are sets of protocols that connect IT systems like electronic health records and third-party apps, allowing them to communicate and share data with one another.
But it can take time for provider-facing IT systems to individually adopt new technologies like APIs, according to Claudia Williams, CEO of Manifest MedEx, an HIE that connects healthcare organizations across California. Williams also served as HHS' director of health information exchange during the Obama administration.
That leaves an opening for HIEs to help hospitals and health plans get data that meets the Fast Healthcare Interoperability Resources, or FHIR, standards in place.
"We can bring in data from any sources, FHIR-ify it—turn it into a FHIR resource—and then be the kind of middleware that can help providers connect to the innovators they want to work with," Williams said.
Manifest MedEx charges hospitals a subscription fee based on net patient revenue. It doesn't charge physician practices and physician-led accountable care organizations for its services, to encourage them to participate.
There's also the potential for HIEs to turn toward the patient population.
"There's an evolving role that some HIEs are contemplating, where they themselves might become the destination for consumer-designated apps to connect," said Aneesh Chopra, former U.S. chief technology officer under the Obama administration and president of CareJourney, a healthcare analytics company.
Instead of a patient linking up an app of their choice to each healthcare organization they visit, the HIE could continue to corral their information. The patient could then connect their app to just one central organization—the HIE.
"That might reduce some of the friction for consumers," Chopra said.
But perhaps the most promising foothold for HIEs to target is providing ADT—admission, discharge and transfer—alerts to providers.
Under the CMS' proposal, many hospitals would be required to electronically notify other healthcare facilities or community providers when a shared patient is admitted, discharged or transferred. It could be a heavy lift for hospitals to establish which physicians at which facilities have a treatment relationship with each patient.
"The hospital may choose to delegate to the HIE the responsibility of validating that the doctor is entitled to the notification, as opposed to manually handling that internally," Chopra said.
Those types of clinical event alerts are a capability that ClinicalConnect HIE in Western Pennsylvania is working to implement, based on demand from its members.
ClinicalConnect HIE's membership fees are based on an organization's operating revenue.
Alerts about patient admissions can help physicians intervene sooner if needed, said Chris Carmody, president of ClinicalConnect HIE and senior vice president of enterprise infrastructure at UPMC, one of the HIE's founding members.
"We're seeing a lot more uses and a lot more opportunities to leverage the data," Carmody said.
It's not enough to exchange data between providers anymore, Williams said.
"Pretty quickly, we're moving from a world of data scarcity to data abundance," she explained. "I think the job of HIEs is transitioning from just the pipe to exchange data … to the job of turning massive amounts of information into insights."
That's likely why HIEs cite the shift to value-based care as an asset for their businesses. That echoes findings from a recent survey from consulting firm Deloitte, which found most technology executives at healthcare organizations—51%—cited the move toward value-based and risk-based contracts as one of the biggest drivers for interoperability.
Growing interest in population health has created new opportunities for HIEs, said Kelly Thompson, CEO of the Strategic Health Information Exchange Collaborative, a national group that represents roughly 80 HIEs, since much of a successful value-based care and population health strategy rests on "people talking to each other who may not have been talking before."
"It seems like such a no-brainer to think that people who are caring for the same patients should be talking to each other," she added.
Regulations like the interoperability rules can only move the industry so far, Chopra said. That's why the biggest push for interoperability—and for businesses like HIEs, third-party apps and more—will likely come from providers and payers seeking to improve care coordination after striking value-based contracts.
"Being compliant with regulations is one thing, but signing an agreement that is the lifeblood of the enterprise, that's a high-order priority," he said. "That may have the fastest effect on accelerating interoperability."